Changes and Revisions to the Administrative Manual
Contracts and insurance policies necessary to the orderly conduct of business shall be maintained.The provision of a service in the absence of a contract is considered to be a constructive contract and need not be formalized by writing. However, when the service provided is directly related to patient care, certain parameters will be adhered to as described below. The original documentation of written contracts will be stored in a secure location.
It is not necessary that every business relationship be formalized with a contract. However, Leadership of this organization assures oversight of contracted services for provision of patient care for safety and effectiveness. (E.g. anesthesia services, pathology and clinical laboratories, diagnostic radiology services) Monitoring activities of patient care contractual agreements will focus on safety and quality of the contracted service. Leadership must approve of the source of the clinical services(s) to be provided through the contract. The nature and scope of services provided through patient care contractual agreements are described in writing and are part of the contract or part of the privileging list as applicable. Expectations are established for the performance of patient care contracted services and are part of the actual contract or privileging list as applicable. Expectations are communicated in writing to the contracted service for patient care. Leadership monitors or evaluates the contracted services for patient care in relation to these expectations annually or more often if indicated.Monitoring is accomplished by: Reviewing information regarding accreditation or certification status as in the case of laboratories Direct observation of the provision of care Audit of documentation, including medical records (E.g. peer review) Review of Incident reports Collection of data that addresses the efficacy of the contracted service (See the QI section of the website, Mandatory audits Test Results) Reference and contract lab services meet the applicable federal regulations for clinical laboratories and maintain evidence of the same. When the expectations are not met, leadership takes steps to improve the contracted services by stating improvements desired in writing to the organization with a cure period, renegotiating or terminating the contract when the continuity of patient care is not maintained. Examples of contracts which may be a part of our records include: 1.Pathology Services,You must have a contract with each lab as well as their CAP certificate or state license. 2.Linen Contract 3.Infectious Waste Disposal Contract The organization must also maintain the document that is returned to the organization stating the infectious waste was disposed of properly.All receipts of pick up and disposal must be stored in one file folder. 4.Air Conditioning 5.Ambulance 6.Anesthesia 7.Fire Extinguisher (contract or bill of sale) 8.Janitorial/Housekeeping 9.Nursing Registry 10. Bio-Medical Engineering Services Contract 11. General Waste Disposal Contract 12. Hospital Transfer Agreement or agreement with an ambulance or documentation of efficacy of 911 call.Such agreement must be proven efficient. 13. Independent Contractor Confidentiality Contract 14. Business Associate (HIPAA) Insurance policies will be established, maintained, and updated on a timely basis.Insurance policies will be kept in a secure location in the Administrative office.Examples of insurance policies include: 1.Professional Liability 2.Fire Insurance Policy 3.General Liability Insurance Policy (including fire and premises liability) 4.Workers Compensation Insurance 5.Personal Liability Policy, when appropriate
Approved By Governing Board